Loro's Pilot program participation application
This application is designed to collect end user’s information that are required for the pilot program and product development. We will request for some of end user’s basic information such as Name, Email, Phone, Medical condition, Wheelchair information, organization association, basic medical expense funding options.
I am? *
Product user information
Information about end user
First name *
Last name *
Email *
Phone *
Area Zip code
What is product user's medical condition *
What age group does the end user belong to? *
Medical condition if other please specify
Wheelchair and assistive devices
Basic wheelchair information and mobile or tablet device used
What smart devices are you using? *
Required
Do you use any of the ability switches like *
Required
Ability switch if other please specify
Where is the wheelchair most likely be used?
About users, caretakers and finance options
This will help us reach the right service provider and stake holders to improve our product services
If you have a caregiver how many hours in a day will you need their help? *
What activity do you expect your caregiver to help you with the most? *
Required
How much is your investment towards your medical devices and services per month? *
Do you use financial aid for your medical expenses from.. *
Financial aid if you other specify
Where do you prefer to buy any of your assistive devices? *
Loro product demo
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